From a comparative perspective the health system of the United States has a history that is both representative and idiosyncratic. Like other advanced industrial nations, it witnessed the rise of biomedicine to professional dominance in the later 19th century, followed by the transformation of the hospital into a temple of high-tech healing, the growth of a pharmaceutical industry ministering to body and mind, and organized structures of access that combined insurance, public funding and private payment. It has been in the balance between these different modes of financing that the disparity between American health care and its peers has been most observed. Unlike other Western nations, which followed either Bismarckian Germany in instituting compulsory health insurance, or inter-war New Zealand in developing a comprehensive state health service, America repeatedly placed more faith in private enterprise. Until relatively recently its doctors exercised greater liberty to practice and charge as they wished, while its commercialized health insurance industry remained voluntary, and its public sector, in the form of Medicare and Medicaid, which arrived only in the 1960s, was limited in coverage to older people and the poor.

As Nancy Tomes points out in the sections which top and tail her new book, this distinctive path had led by the millennium to a system that many citizens found dysfunctional. Problems included the absence of universal access for a large proportion of the population, the inflexibilities and exclusions of private health insurance, a distorted balance of care that marginalised general practice, and some inherent tendencies to overtreatment and over-prescribing. By all the standard measures, the American way has also proven hugely more expensive than that of peer nations, without appreciably superior health outcomes. The result was the fierce and ill-tempered political debate which in 2010 was resolved (probably only temporarily) with the Affordable Care Act (aka ‘Obamacare’).

A very rich historiography abounds on the American health care sonderweg, concentrating particularly on the relationship between government and the big battalions of this policy arena, namely the American Medical Association (AMA), the private and non-profit insurers, the employers and the labour unions. Scholars typically concentrate on signal moments (the Progressive era, the New Deal, the post-war settlement, the Great Society, the neo-liberal turn, ‘Hillarycare’) when the reform initiatives of federal government were repeatedly frustrated by one or other, or all, of the major interests. The novelty of Nancy Tomes’ approach is to shift the spotlight onto a different power relationship in health care’s political economy, that between the public and the medical-industrial complex.

The public is here conceptualized quite narrowly as the ‘patient-consumer’, by which Tomes intends the educated middle class seeking to hold medicine to account. This definitional boundary rules out activism by, or on behalf of, sick patients, whether in its early form of advocacy charities or in today’s ‘embodied social movements’. Instead consumerism is understood as the furtherance of the public interest through transparency and watchdog activities, of the sort purveyed in the US by Ralph Nader and in Britain by the Consumers’ Association. Medicine is here understood both as the work of free enterprise, office-based physicians, rather than hospital practice, and as the wholesale marketing end of the pharmaceutical business, rather than the industry as a whole. In other words, Tomes has carved out a manageable project by delimiting Main Street America as the field of study, albeit this largely excludes the experiences of the sick and the poor, and their interface with significant parts of the health system.

Although the book is not as heavily theorised as much work in this area (of which more later) Tomes lays her cards on the table at the outset, advising readers she does ‘not worship in ... the “church of the free market”’ (p. 15). In her conclusion, she acknowledges that within that marketplace patient-consumers had made progressive gains in the 20th century. These include greater responsiveness by doctors in their daily interactions, better information about prescription drugs, and the gradual improvements in coverage and security that culminated in the Affordable Care Act. However, ‘(t)aking off the rose-colored glasses’ (p. 399) forces the greater realisation that the public interest has repeatedly been sidelined throughout this history. In medicine, the economic liberal’s assumption that the discriminating buyer will ensure efficient pricing and consumer-oriented service has time and again been invalidated. On balance, the market power of the profession and industry has always proven too much for the ‘engaged patient’. The substance of the book charts this process.

The discussion begins in the Progressive era, though with a concertinaed backward glance to the 19th century, to observe the rise to dominance of biomedical practitioners in a hitherto ‘freewheeling’ marketplace for cures. A key early milestone was the 1906 Pure Food and Drug Act, which asserted the principle of statutory intercession on behalf of the public. It also drew the lines of conflict for the coming century, over how far commercialism should legitimately intrude into the realm of health care. These dilemmas crystallised in the inter-war years as the trappings of mass consumer society fell into place, with ever more sophisticated inducements to buy health care. Streams of doctors, mostly white, male and middle class, flowed from reformed medical schools to set up office practices, with charges commensurate to their professional claims, while new style drugstores successfully adopted the latest advertising and marketing techniques.

In response came the first stirrings of the ‘educated’ patient, and one of the pleasures of this book is the deftness with which Tomes ranges across the sources through which a growing frustration with commercialized medicine can be viewed. These include humorous satires of gullible purchasers and avaricious providers, early exposés of unsafe drugs, guides produced by consumer organizations to help the health care shopper, and debates surrounding federal proposals for curbs on advertising. All this prompted the resistance of the medical profession, particularly in the depressed 1930s when the Committee on the Costs of Medical Care (CCMC) comprehensively mapped the system-level market failures to which unregulated health care had led. Yet New Deal reformers backed off from including health within the social security package, in face of AMA lobbying. Hence by the mid-century only a more limited coverage based on workplace and voluntary insurance tempered private medicine. In the post-war period, therefore, the informed patient consumer would become more important than ever.

Initially America’s ‘free enterprise’ approach to medicine seemed well chosen post-1945, even as most Western nations took other choices. Its post-war boom successfully brought much of the population under insurance schemes, some in the form of group prepayment plans offering comprehensive, cost-controlled services. Technological advance now promised genuinely effective medicinal cures, and appetites for pharmaceuticals were further stimulated by the arrival of the self-service drugstore and televised advertising. Legislation promoted by the Food and Drug Administration (FDA) restricted over-the-counter (OTC) sales of ‘dangerous’ medication (particularly narcotics), though information on prescription drugs was still lacking. The 1950s though was the swansong of the (partly mythical) ‘family doctor’ whose relationship with the patient was based on trust not commerce.

As in other walks of life, it was the American Sixties that finally brought change. Resentment had grown towards ever-rising yet ever-opaque medical bills, towards unsafe surgery and towards the expectation of patient deference. Now liberal federal reforms empowered the FDA to approve new drugs, while Medicare and Medicaid extended access to the uninsured. At the grassroots a new breed of health activist campaigned for racial, gender and social equality, with community clinics providing a different model of care. In the event though, the radical promise remained unfulfilled. Medicine under social security merely fuelled existing problems, by failing to contain costs or disincentivise excess treatment, but now with the deep-pocketed state as payer. A more positive legacy of the era was the fully-fledged emergence of the critical medical consumer, conscious of patient rights and armed now with data through which to force accountability.

The closing chapters of the book describe the duel danced in recent decades between this engaged public and the medical establishment, as policy veered between a full-blooded reassertion of free enterprise and a concern to rein back the expenditure hike which this inevitably fuelled. Reaganite hostility to ‘red tape’ loosened the strictures on approval of new drugs and worked against the information sharing needed for consumer choice. Restraints on aggressive advertising were lifted, making it harder for active consumers to disentangle useful facts form corporate blandishments. The rise of the ‘big-box’ drug supermarket ratcheted up the commodification of OTC pharmaceuticals yet further. Then came ‘direct-to-consumer’ advertising of prescription drugs, whose massive industry investment paid off with handsome returns. Meanwhile, the shift to ‘managed care’ constrained the autonomy of both physicians and patients within insurance systems in the name of cost control. Against all this, the weapons of critical consumption became more sophisticated, with outcome measures and scalar ranking of performance now available. However, for most patients these resources were no match for the larger economic forces which now shaped the medical encounter. Hence the pessimistic conclusion Tomes advances, as her story arrives in the present day.

All this is written in a vivid and engaging style, which makes a complex history easily available to lay readers and satisfying for specialists. Tomes moves with ease between pithy anecdotes, artifacts of popular culture, vignettes of earnest advocates or self-righteous doctors, and the high politics of health care. The result is a narrative with pace and direction. The only disappointment is that the publishers have seen fit to gather all the illustrations together, without cross-referencing, in the centre of the book instead of placing each at the appropriate point in the text. Thus, the impact of some of Tomes’ sharpest aperçus, on cartoons, advertisements and suchlike, is blunted for the reader and a trick missed.

How then does the book contribute to larger understandings of the American health system, and of medicine’s modern history? Tomes has headed off two potential complaints when justifying the boundaries of her subject. The first is that concentration on the middle-class ‘engaged patient’ excludes other sections of the public, those whose power in the health care marketplace gave them less capacity to act as critical consumers. She quite reasonably argues (pp. 14–15) that having opened up the research area it will be for others to flesh out the story of how poorer and less educated people interacted with the ‘free enterprise’ system. However, this does raise the question of whether she underplays the extent of inequality to which American medical commerce gave rise. She gives occasional glimpses of this, for example in a graph reproduced from the CCMC report (p. 201), showing major variation in per capita expenditure between different survey communities. But further consideration of how those with minimal resources navigated relations with physicians and pharma may well modify her appraisal, probably for the worse.

A second issue arising is how much of what she relates is generic to medicine in the advanced industrial nations, and how much specific to the US and its particular policy choices. In the British context for example, histories of the patient-consumer have a different emphasis, focusing both on voluntary associations external to the National Health Service, and on structures within the service designed to encourage (in the jargon) ‘patient and public involvement’. Yet here too recurrent scandals in hospital care have raised doubts about how much real influence the public has exerted, and scholars have noted the shallowness of the consumerist rhetoric of ‘choice’ that health ministers regularly deployed. Conversely, the brashness of US drug advertising would be unrecognisable elsewhere, and the tighter evaluation regimes of some European countries, based on gauging cost per ‘quality-adjusted life-year’, have checked exaggerated marketing claims by big pharma.

Hopefully then, the comparative history of the patient-consumer will be a future legacy of Nancy Tomes’ work. However, both these unfinished issues play into a larger question that her book provokes, but leaves hanging. She has provided a superb narrative history, which culminates in a convincing appraisal, but arguably she leaves the problem of why things happened as they did insufficiently resolved. One of the attractive features of the historiography of American medicine is the extensive theoretical underpinning it has accumulated, with competing schools of thought jostling for attention. Readers interested in thinking through the implications of this study therefore have some rich resources on which to draw.

Ought we, for example, to see this rumbustious commercial system, with all its faults, as nonetheless the legitimate democratic outcome of the public will? This would accord with political scientists who have treated the health policy arena as one of pluralist negotiation, in which the state brokers the fairest compromise. It also chimes with a recent strand of economic history that argues Americans repeatedly rejected statist or compulsory insurance approaches for utilitarian reasons – they were always less attractive to voters than earnest reformers assumed. There is also the related argument first voiced in Parsonian sociology, and in cruder form, repeatedly, by politicians, that the American health system has always reflected its distinctive political culture, in which the celebration of individual liberty trumps the appeal of equality and fraternity. In these senses the failures Tomes recounts, though depressing, were simply the price of freedom.

Many of course see things otherwise. Veteran Marxists view the relation through a class prism, in which the state must always act first for capitalistic interests, and thus tends to support the market position of doctors and the drug industry. Change can only come from the labour movement (conspicuous in the book by its absence), which either forces a legitimation crisis or builds its own grassroots alternatives. Yet this did not happen in the US, in which socialism was famously muted. The very emergence of the medical ‘consumer’ is therefore a regrettable artifact of capitalist hegemony. Then there are less dogmatic sociologies of power, depicting health politics as essentially a two-way tussle, between the doctors – ‘professional monopolisers’ whose negotiating strength came from their specialist skills – and the big purchasers of care – ‘corporate rationalisers’ in the insurance funds or government, whose economic muscle was exercised on behalf of the payers. Somewhere in the middle were the patients – a ‘repressed interest’, ever hopeful of equitable, low-cost, high-quality care, yet ever ignored because they held no leverage. Perhaps Tomes’ account could be understood in some of these terms, less as linear narrative than as a recurrent playing out of conflict between structural forces.

Finally there is the historical institutionalist approach that currently rides high in the literature. This draws attention to the political process in time, showing how early policy decisions established feedback effects through creating interest groups, and setting expectations. These then locked-in a policy trajectory that proved very hard to break, even when its malfunctions became widely apparent. The focus also is on the nature of American government, with its vulnerability to moneyed pressure groups and its byzantine legislative obstacle course, which afforded opponents many veto points to block progressive reform. This raises the question of whether behind Tomes’ history may lie a linking thread of interest group interaction with politicians that merits a more explicit exposure.

From what has already been said, it will be clear that Tomes’ position on these questions is far from equivocal, even if she resists providing an extensive conceptual exegesis. This offers an exciting prospect for others to engage with her work and reflect on how it augments our general understanding of health system dynamics and policies, both nationally and comparatively. For now, this is a big, original contribution to the field, which signposts important directions for future study.

March 2017

Author's Response

Nancy Tomes

Posted: Tue, 04/04/2017 - 14:52

Let me start with a thank you to Martin Gorsky for writing such a perceptive review of my book and to Reviews in History for giving me an opportunity to reply. Encouraging this kind of exchange is yet another way that online, open source journals benefit the historical profession.

In my view, Professor Gorsky’s commentary is a model of what good reviewing should be: an accurate summary of the author’s main arguments along with intelligent criticisms of them. I share his assessment of where the book feel short. So, this response will not be a querulous rebuttal but rather an attempt to explain further why I made the choices I did, especially as they bear on the ‘idiosyncratic’ aspects of the American story.

Professor Gorsky quite correctly points out that Remaking the American Patient does not engage much with the theoretical debates about why health care systems differ, debates that Professor Gorsky does a nice job of laying out in the mid-part of the review. I am in fact quite interested in those debates and hope to contribute more directly to them in the future. But as Professor Gorsky observes, I had a different agenda in writing this book. In recent years, historians have been urged to step outside of their academic comfort zones and try to communicate their findings to a broader audience. In my case, I wanted to craft a narrative overview of the 20th-century medicinal profession that would simultaneously connect medicine’s evolution to larger themes in American history (consumer culture, the shift to a post-industrial service economy) while also addressing contemporary issues of concern to doctors and patients. Rather than write a trade book, which would have required a drastic shortening of the text and elimination of the footnotes and bibliography, I went with a good university press that allowed me to produce a ‘doorstopper’, as my editor called it – a very long book with lots of footnotes. I hoped to find the sweet spot: to write a work that historians would find substantial while also appealing to non-academic readers. In the process, I did slight the extensive theoretical and historiographical debates that have bear on the differential development of modern health care systems.

That said, Remaking the American Patient did attempt to make a modest contribution to contemporary policy discussions in the United States (as distinct from academic debates) in ways that might not be so apparent to historian readers. In this country, health care policy is heavily dominated by economists whose models of how the health care system should be ‘fixed’ depend heavily on mechanisms of patient-consumer choice. I became intrigued with those models while participating in the Robert Wood Johnson Foundation’s investigator award program, which brought me into regular contact with economists, political scientists, and sociologists studying the American health care. Listening in on those discussions, I was amazed at how under-historicized the roles of patients as economic actors were. Despite the growing policy weight placed on ‘educating’ Americans to make ‘better’ choices as a corrective to the system’s many dysfunctions, economic as well as therapeutic, there was surprisingly little work on the impact of consumerism as a historical phenomenon. I hoped by historicizing the ‘patient-as-consumer’ that I might in some small way contribute to a more realistic approach to health care reform. That was a naïve hope on my part; as the latest effort to repeal the Affordable Care Act shows, thoughtful policy debate has no place in the current politics of American health care. But I do not regret making the attempt, even if it felt much like bashing my head against a brick wall.

Those policy interests also influenced my efforts to locate medicine within the larger context of American culture. Much excellent historical work has been done in the past few decades on the evolution of basic institutions (medical schools, hospitals, medical specialties, pharmaceutical firms), on patient experiences with specific diseases and processes (tuberculosis, cancer, diabetes, mental illness, pregnancy, reproductive health), and on the powerful role that class, race, gender, and region play in shaping those experiences. Rather than replicate that work, I decided to look at the other end of the funnel, so to speak, and study the doctor’s office and the drugstore, two sites of care that have received very little historical attention. That pairing also reflected my interest in locating medicine within the larger context of American consumer culture, advertising, and consumerism. There has been a huge literature on those subjects in recent years, little of which directly considered medicine and health. By looking at the doctor’s office and the drugstore, I wanted to explore the interplay between the dynamics of modern consumer culture and the contours of modern biomedicine.

Those choices of emphasis did tilt my history toward the consumerism practiced by white educated middle-class patients. That problem bothered me throughout the writing of the book; had I more energy and another 200 pages available to me, I would have done more to move beyond the focus on the articulate and affluent. It was certainly not my intent to ‘underplay the extent of inequality’. But I thought there was no need of another book demonstrating that the American system fails to care for the poor, recent immigrants, people of color, and other vulnerable groups. We have a mountain of historical, social scientific, and clinical studies attesting to that fact. What is less apparent is how badly the health care system has served even the entitled people who are ‘supposed’ to be doing well within it. Current American health care policy works from the assumption that if only they ‘choose wisely’, the system works reasonably well for discerning people blessed with good insurance. That assumption drives the efforts to ‘fix’ the system primarily by making it more accessible to everybody else. I wanted to question the idea that expanding access alone was going to solve the system’s problems, and to push back against the rampant patient-blaming that has become endemic to political discussions in this country. At the same time, I did not want to dismiss the grassroots struggles of the past or present as useless or meaningless. This conundrum made for a difficult interpretive task. Simultaneously to criticize and defend the concept of critical consumerism.

As to the representative or idiosyncratic question, I have no sense yet of how relevant or useful historians outside the United States will find my study. I had so much trouble figuring out what was going on in the US that I rarely extended my gaze to other places. When I did, it was chiefly to describe how American critics invoked comparisons to other countries to benchmark American deficiencies. One of the pleasures of finishing a book that took 15 years to write is that I now have the luxury of discussing it with my colleagues. Frank Huisman has invited me to come to the Descartes Centre at Utrecht University this summer to start that conversation; we have plans for a future conference to which we can invite Professor Gorsky and other historians to think more about the comparative history of health care systems. I look forward to that opportunity.

As one final point, I want to explain that putting all the illustrations together was a cost savings measure. I was fortunate that the University of Carolina Press was willing to take a chance on publishing such a very long book (over 500 pages), which is a rarity in academic publishing today. But to keep the cost down, we did have to economize on issues such as the placement of the illustrations.